Documenting Relatedness and Its Role in Payment-Related Scrutiny

Outline:

Objectives

Case Scenario — Mrs. OutofBreath

Question: Who is the Sicker Patient?

Case Scenario — Mrs. OutofBreath

Question: Who is the Sicker Patient?

Everyone, Put Your Hospice Hat Back On

So, Hit the Easy Button…

History of Relatedness Determination and Hospice Care

How did We Get Here? Cycle of Payment-Related Scrutiny

Cycle of Payment-Related Scrutiny

The OIG, Relatedness Determination, and Outside of Hospice Spending

CMS Statements of Relatedness

CMS Regarding Diagnosis and Coding

Medication Coverage, Part D, and PEPPER

PEPPER: Part D Claims per Beneficiary at Home

PEPPER: Part D Claims per Beneficiary in a Nursing Facility

Strategies to Relatedness Determination

Determining Relatedness to the Terminal Prognosis Process Flow

NHPCO Relatedness Process Flow

Determination of Hospice Medication Coverage

Hospice Medication Payment Responsibility

Where Quality Meets Compliance

Key Components

Documentation of Relatedness

Example: Mr. Heartbroken

Determining Relatedness to the Terminal Prognosis Process Flow

Mr. Heartbroken: Medication List

Determination of Hospice Medication Coverage

Mr. Heartbroken’s Diagnoses Are All Related to His Terminal Prognosis but Are His Medications Medically Indicated?

We Need More Information

Mr. Heartbroken’s New Med List

How to Perform a Med Review

Example Documentation of a Related Condition and Medication Not Indicated

Example Documentation of an Unrelated Condition and Medication

Deprescribing Resource

Final Word: CMS and Relatedness Determinations

Dr. Lauren Templeton has been a Physician Consultant with Weatherbee Resources since 2017. As a physician since 2009 and a hospice and palliative medicine physician since 2012, Dr. Templeton began her career in internal medicine, but soon thereafter was drawn to end-of-life care due to its overall philosophy and her passion for ensuring a dignified death for her patients. As a hospice medical director and Hospice Medical Director Certified physician, she is perfectly positioned to assist your hospice physicians with compliance education!

Dr. Templeton currently works in hospice as the medical director for a medium size not-for-profit hospice based in Texas. In this role, she assists with compliance, quality improvement and documentation review. She continues to participate in clinical care managing hospice patients in both the home care and inpatient setting.

Dr. Templeton also serves as associate medical director for the Palliative Care Department at a local medical center, as well as, serving on the foundation board, medical executive committee, and ethics committee for the same facility.

Dr. Templeton’s mission is to help support hospices by educating on the role of the hospice medical director from a regulatory and clinical perspective. She has served as a task force member and item writer for the Hospice Medical Director Certification Board from which she is certified. She continues a robust educational program within her own hospice program and is a regular speaker with the Texas New Mexico Hospice Organization.

Dr. Templeton is an advocate of the hospice benefit and speaks to groups such as the Alzheimer’s Association about hospice care. She currently serves as a member of the NHPCO Regulatory Committee assisting in advocating for hospice providers across the country.

As a Physician Consultant with Weatherbee, Dr. Templeton assists hospice providers and physicians with compliance services as well as:

• Orientation for new medical directors and team physicians.
• Education, coaching, and mentoring for hospice physicians.
•  Consulting on complex issues (e.g., making appropriate coverage determinations; ethical issues; challenging pain and symptom management cases; admission, recertification, and level of care eligibility; etc.).
• Auditing physician and other clinical record documentation (e.g., thoroughness and appropriateness with regard to hospice eligibility; compliance with regulatory requirements; appropriateness with regard to coverage determinations; etc.).
• Re-tooling the interdisciplinary group meeting and related processes.
• Preparing physicians for Administrative Law Judge (ALJ) hearings.
• Providing expert witness testimony in ALJ hearings and other legal matters involving patient eligibility.

Dr. Templeton graduated from Pennsylvania State University with a Bachelor of Arts and received her doctor of osteopathy from Ohio University College of Osteopathic Medicine in 2009. She completed a residency in Internal Medicine and is board certified with the American College of Osteopathic Internists. She completed a fellowship in Hospice and Palliative Medicine at Texas Tech University and became board certified in hospice and palliative medicine in 2013. She obtained additional certification with the Hospice Medical Director Certification Board in 2018.

In November 2022, Dr. Templeton earned the designation Fellow of the American Academy of Hospice and Palliative Medicine (FAAHPM). This is the highest honor that can be bestowed upon a member. The Academy is the professional organization for physicians specializing in hospice and palliative medicine, nurses, and other healthcare providers.